2010.03

RELEASE & AUTHORIZATION TO PHOTOGRAPH, VIDEOTAPE OR AUDIOTAPE SEDONA HISTORICAL SOCIETY

P.O. Box 10216, Sedona, Arizona 86339, 928-282-7038 www.sedonamuseum.org sedonamuseum@esedona.net

I, ____________________________________________________________ hereby agree to be photographed, tape recorded and/or video taped by the Sedona Historical Society or its duly authorized representative, and forever authorize the Sedona Historical Society to use and display the photographs, tape recordings or video tapes as part of any exhibit or for any purpose or use that is consistent with the purposes of the Sedona Historical Society and the Sedona Heritage Museum. The undersigned does hereby irrevocably grant the Sedona Historical Society and their successors or assigns these rights to use in perpetuity. I hereby forever release and discharge the Sedona Historical Society, and its members, directors and officers from any claim I may have for compensation of any type which I might be entitled to for the use, display or publication of photographs, tape recordings and videotapes. I hereby forever release the Sedona Historical Society and its members and the Sedona Heritage Museum from any and all claims for damages for libel, slander, invasion of privacy, or any other claim based on the use of said material(s). Name:__________________________________________________________________ Address:________________________________________________________________ City, State, ZIP:__________________________________________________________ Phone: _________________ email: _________________________________________ Description of materials: _________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Signature: _____________________________________ Date:_________________